Chapter 9 – Sexually Transmitted Infections

Learning Outcomes

• Develop a plan to implement safer sex practices with partners and ways to discuss sexual health with healthcare providers.
• Compare and contrast treatment options for sexually transmitted infections and ways to outreach to diverse community members about STI prevention and intervention utilizing health psychology and community-based educational techniques.
• Analyze and address the unethical and inhumane research regarding STIs paid for by the United States government.

Introduction

Topics addressed this week will include safer sex practices, history of sexually transmitted infections (STIs a.k.a. sexually transmitted diseases or STDs), symptoms, treatments, and statistics. Tips on how to talk with healthcare providers and partners about STIs will be provided. The harmful past (and still ongoing) wrongs committed by researchers will be analyzed and called out as they intersect with race, poverty, nationality, and gender. Distrust of medical research and regarding the development of treatment options remains among many minority groups due to the unethical research that was done. In moving forward, what are the best ways to outreach to reluctant participants who have reason to question motives based on these historical experiences?

Talking with Partners about Safer Sex Practices

Preventing STIs starts with developing skills to talk with partners about safer sex practices. Here is a video from Planned Parenthood (2017) on how to talk with partners about “Safer Sex”:

How to Prevent Sexually Transmitted Infections: Safer Sex Techniques

Abstaining from sexual behaviors, such as anal, vaginal, or oral sex in which you physically come into direct contact with another person’s bodily fluids and skin, is the only way to prevent the transmission of an STI (Centers for Disease Control and Prevention [CDC], 2020). Some sexual behaviors in which you are not directly in contact with others’ bodily fluids or skin, such as masturbating in front of each other, touching body parts through clothing, and more, can be done safely as well. Keep in mind, STIs are transmitted through contact with skin anywhere on the body that might have an active viral load and others are spread through the exchange of bodily fluids. As direct, naked, and penetrative contact increases, so do the risks of STI transmission.

Vaccination against certain viral STIs, such as hepatitis A and B and human papillomavirus (HPV), are important prevention measures (CDC, 2020). Vaccinations for HPV are recommended beginning as early as age 9 through age 26, and individuals 27 and older have less benefit from a vaccine due to likely already being exposed (CDC, 2020). Ask your healthcare provider about being vaccinated for HPV if you are 27 years and older as it is possible to have not been exposed prior depending on previous sexual activity history. Hepatitis vaccines are recommended at any age if not previously inoculated. Most children in the United States receive hepatitis B vaccinations as requirements to attend public school with very limited mandates regarding HPV vaccination throughout the United States (North & Niccolai, 2016). As of 2014, HPV vaccination rates were at about 60% for girls and about 42% for boys in the United States (North & Niccolai, 2016).

Condoms should be used every time when engaging in penetrative sexual behavior with a new partner in which a penis is entering a vagina, anus, or mouth. Often referred to as a “male” condom, “external” condom, or just “condom,” this type is meant to be rolled down over the penis (CDC, 2016b). Check out these infographics provided by the CDC on “The Right Way to Use a Male Condom.” Commonly referred to as a “female” condom or “internal” condom, this type of condom is placed within the vagina until it rests against the cervix with the outer ring remaining outside the body. They can also be used anally by using the fingers to place the internal condom. It is especially important that the outer ring remains outside the body in order to not get lodged internally. Check out another infographic from the CDC on “The Right Way to Use a Female Condom.” Next time you are at the store, try to find and compare different types of condoms. According to Planned Parenthood (2021a), internal condoms are harder to find and may require a prescription to purchase at some drug stores.

Dental dams can be used during oral sex (using the mouth to pleasure the penis or vulva) or anilingus (more commonly known as “rimming” or providing pleasure to the anus with the mouth) as a protective barrier. Check out the CDC infographic on “How To Use A Dental Dam As A Barrier For Oral Sex,” which also provides guidance on how to create a dental dam out of a condom.

Safe sex with sex toys is important to reduce the likelihood of spreading STIs by using mild soap and water in between uses and before sharing the toy with a partner (Planned Parenthood, 2021b). Condoms can also be used on some types of toys, such as dildos, as long as the condom is changed to a clean one in between uses as well (Planned Parenthood, 2021b).

Mutual monogamy is when two people within a relationship agree to be exclusive or only sexually active with one another (CDC, 2020). After being tested for STIs, engaging in sexual behaviors is safe as long as no new partners are engaged with sexually. A common issue with this is that an individual within an agreed-upon monogamous relationship may cheat and expose the partner to STIs since using safe sex practices may alert the partner that something has changed requiring protection (Lehmiller, 2015). Safer sex in consensually non-monogamous relationships, such as using condoms with primary and additional partners and getting tested more frequently for STIs, was practiced more frequently than in monogamous relationships (Lehmiller, 2015). In the study by Lehmiller (2015), about 25% of the monogamous participants reported having sex outside their primary relationship with a majority of these individuals stating their primary partners did not know about this.

Getting tested and knowing your STI status is vital to preventing the spread of STIs. Individuals who are engaging in unprotected sexual behaviors with new partners or have partners who are engaging in sexual behaviors with other people should be tested at least once a year (CDC, 2014). Pregnant individuals should be tested early in pregnancy and testing should be repeated if necessary depending on sexual behavior and risks (CDC, 2014).

Check out “Your Safer Sex Toolkit” by the American Sexual Health Association that includes questions for you to decide your own “safer sex boundaries” based on what is most important to you as well as additional information on safer sex techniques.

This “LGBTQIA Safer Sex Guide” by Healthline (2020) is another helpful resource, which also includes information regarding ways to be safer while engaging in “outercourse,” “hand sex,” and more.

For ways to better outreach to men who are African American, straight, and 18-30 years old about safer sex practices, the American Sexual Health Association (2015) developed the “Health is Power” Toolkit to be used by their partner agencies. This toolkit provides guidance to sexual health organizations on ways to better outreach to and educate community members with these particular intersecting identities.

History of the Most Common STIs

The following timelines will provide background concerning how the understanding of STIs has changed over time. The information summarized in this section is taken from Britannica (2020).

Gonorrhea and Syphilis

• Gonorrhea named by an ancient Greek physician, Galen
• Gonorrhea was present in ancient Egypt and China as well
• An epidemic of Syphilis was reported in Europe in the 1490s
• In the 1930s, effective medications (sulfa drugs and penicillin) were used to treat both syphilis and gonorrhea
• Eradication was expected but the lack of people using safer sex practices and the development of antibiotic-resistant strains caused infections to rise by the 1950s
• Gonorrhea and syphilis were thought to be the same until the early 20th century
• Gonorrhea and syphilis remain global health concerns today

Herpes

• Herpes became prevalent in the 60s and 70s
• No cure but symptoms can be reduced (remission) through the development of antiviral medications

HIV/AIDS

• HIV clearly identified in 1981 and AIDS, which develops from untreated HIV
  • Gay men in the US and western Europe and straight individuals in tropical Africa were at the greatest risk of infection due to lack of access to education and resources regarding safer sex practices
  • Communities were devastated as many people died

STIs: Symptoms, Classifications, and Treatments

General symptoms will be addressed and STIs will be broken down by whether they are caused by a bacteria, virus, etc. because treatments may be similar for many of the STIs that fall under each of these categories.

General Symptoms to Look Out For

According to the National Institutes of Health (NIH, 2017b), some people may have an STI and experience no symptoms which is why getting tested is best. Others may experience an immune response in which they feel ill. Common symptoms of STIs include (NIH, 2017b):

• Unusual discharge from the penis or vagina; this can sometimes be discolored as well (yellowish, greenish, etc.)
• Blisters, sores, or warts on the genital area
• Painful or frequent urination
• Itching and redness on or around the genitals
• Blisters or sores in or around the mouth
• Abnormal vaginal odor
• Anal itching, soreness, or bleeding
• Abdominal pain
• Fever or chills

Check out this factsheet from the CDC (2011) on “10 Ways STDs Impact Women Differently from Men.”

Bacteria

Types of bacterial infections:

Treatment

• Antibiotics (NIH, 2017a)

Viral Infections

Types of viral infections:

• Human Papillomavirus (HPV)
  • Genital warts and some types of cancers (i.e. cervical) are side effects
  • Vaccines have been developed
• Herpes
  • Cause sores on parts of the body; can still be contagious without a sore present if the viral load is high enough
  • No cure, but outbreaks can be reduced or prevented with antiviral medications
• Human Immunodeficiency Virus (HIV)
  • Acquired Immune Deficiency Syndrome (AIDS) develops from untreated HIV
  • The virus interferes with the functioning of the immune system and weakens the body’s ability to fight off diseases and infections
• Hepatitis B (HBV)
  • Infects the liver and can lead to chronic liver disease if untreated
  • Vaccines have been developed
• Hepatitis A (HAV) and Hepatitis C (HCV)
  • Infects the liver, causing damage
  • Less common than HBV

Treatments

• Antiviral medications
• Vaccines that increase the immune system’s ability to fight off the virus and prevent the illness
• Drugs that prevent transmission that are taken by an individual before they are potentially exposed to a virus by an infected person (i.e. PrEP for HIV)
• Antiretroviral medications, such as for HIV, work by preventing the life cycle of the virus from continuing to the next stage (NIH, 2017a)

Here is another resource from the CDC regarding “HIV Treatment.”

Parasites

Types of infections due to parasites:

• Trichomoniasis
  • Parasite in ejaculate/vaginal fluids
  • Treated with an antibacterial medication
• Pubic lice
  • Commonly known as “crabs”
• Scabies

Treatments

• Insecticide cream
• Insecticide oral medication

Fungus

• Candidiasis (yeast infections)

Treatment

• Antifungal medicine

Statistics and Education versus Stigma and Shame

Due to the way that our society discusses STIs, they are often associated with words like “dirty.” This leads to discomfort or worry when discussing them with healthcare providers and partners. Let’s take a look at the statistics in order to educate about the prevalence and risks of contracting various STIs. Various organizations are also actively trying to undo the stigma and shame by creating community education campaigns around ways to talk with healthcare providers and partners about STIs.

Statistics

The following statistics are from the American Sexual Health Association (ASHA, 2020).

1 in 2 people who are engaging in sexual behaviors will get an STI by the age of 25

Human Papillomavirus (HPV)

• 80% of sexually active people have HPV
  • HPV vaccine has been very helpful (64% reduction in younger individuals)

Herpes

• 1 in 2 people have oral herpes
• 1 in 8 have genital herpes
• 90% don’t know they have either type

Chlamydia, Gonorrhea, and Syphilis

• Most commonly reported
• Young people most at risk
• Annual screening recommended but rarely followed
• 2013-2016 diagnosis for all 3 on the rise
• PID results when untreated from gonorrhea and chlamydia leading to infertility in 1 in 8 women

Hepatitis

• Hepatitis B drastically decreased by 82% since 1991 due to routine vaccination of children
• Hepatitis C most common among baby boomers (born 1945-1965); they are 5 times more likely to have this

HIV

• In the US, 1.1 million people are living with HIV; 1 in 7 don’t know
• PrEP reduces HIV infection risk up to 92%

Undoing Stigma and Shame: Moving Forward

Check out this campaign by ASHA that is seeking to reduce stigma around STIs in order to encourage people to get tested called, “Yes Means Test.”

How to Talk with Healthcare Providers and Partners about Getting Tested

How to Talk about Having an STI with Partners

The Tuskegee Timeline

This following content is currently under review by CDC to ensure the content is accurate and verifiable.

The Study Begins

In 1932, the Public Health Service, working with the Tuskegee Institute, began a study to record the natural history of syphilis in hopes of justifying treatment programs for blacks. It was called the “Tuskegee Study of Untreated Syphilis in the Negro Male.”

The study initially involved 600 black men – 399 with syphilis, 201 who did not have the disease. The study was conducted without the benefit of patients’ informed consent. Researchers told the men they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anemia, and fatigue. In truth, they did not receive the proper treatment needed to cure their illness. In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance. Although originally projected to last 6 months, the study actually went on for 40 years.

What Went Wrong?

In July 1972, an Associated Press story about the Tuskegee Study caused a public outcry that led the Assistant Secretary for Health and Scientific Affairs to appoint an Ad Hoc Advisory Panel to review the study. The panel had nine members from the fields of medicine, law, religion, labor, education, health administration, and public affairs.

The panel found that the men had agreed freely to be examined and treated. However, there was no evidence that researchers had informed them of the study or its real purpose. In fact, the men had been misled and had not been given all the facts required to provide informed consent.

The men were never given adequate treatment for their disease. Even when penicillin became the drug of choice for syphilis in 1947, researchers did not offer it to the subjects. The advisory panel found nothing to show that subjects were ever given the choice of quitting the study, even when this new, highly effective treatment became widely used.

The Study Ends and Reparation Begins

The advisory panel concluded that the Tuskegee Study was “ethically unjustified”–the knowledge gained was sparse when compared with the risks the study posed for its subjects. In October 1972, the panel advised stopping the study at once. A month later, the Assistant Secretary for Health and Scientific Affairs announced the end of the Tuskegee Study.

In the summer of 1973, a class-action lawsuit was filed on behalf of the study participants and their families. In 1974, a $10 million out-of-court settlement was reached. As part of the settlement, the U.S. government promised to give lifetime medical benefits and burial services to all living participants. The Tuskegee Health Benefit Program (THBP) was established to provide these services. In 1975, wives, widows and offspring were added to the program. In 1995, the program was expanded to include health as well as medical benefits. The Centers for Disease Control and Prevention was given responsibility for the program, where it remains today in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. The last study participant died in January 2004. The last widow receiving THBP benefits died in January 2009. There are 11 offspring currently receiving medical and health benefits.

Important Timeline

1895 – Booker T. Washington at the Atlanta Cotton Exposition, outlines his dream for black economic development and gains support of northern philanthropists, including Julius Rosenwald (President of Sears, Roebuck and Company).

1900 – Tuskegee educational experiment gains widespread support. Rosenwald Fund provides monies to develop schools, factories, businesses, and agriculture.

1915 – Booker T. Washington dies; Robert Moton continues work.

1926 – Health is seen as inhibiting development and a major health initiative is started. Syphilis is seen as a major health problem. Prevalence of 35 percent observed in the reproductive age population.

1929 – Aggressive treatment approach initiated with mercury and bismuth. Cure rate is less than 30 percent; treatment requires months and side effects are toxic, sometimes fatal.

“Wall Street Crash”–economic depression begins.

1931 – Rosenwald Fund cuts support to development projects. Clark and Vondelehr decide to follow men left untreated due to lack of funds in order to show the need for treatment programs.

1932 – Follow-up effort organized into study of 399 men with syphilis and 201 without. The men would be given periodic physical assessments and told they were being treated. Moton agrees to support study if “Tuskegee Institute gets its full share of the credit” and black professionals are involved (Dr. Dibble and Nurse Rivers are assigned to study).

1934 – First papers suggest health effects of untreated syphilis.

1936 – Major paper published. Study criticized because it is not known if men are being treated. Local physicians asked to assist with study and not to treat men. Decision was made to follow the men until death.

1940 – Efforts made to hinder men from getting treatment ordered under the military draft effort.

1945 – Penicillin becomes accepted as treatment of choice for syphilis.

1947 – USPHS establishes “Rapid Treatment Centers” to treat syphilis; men in study are not treated, but syphilis declines.

1962 – Beginning in 1947, 127 black medical students are rotated through units doing the study.

1968 – Concern raised about ethics of study by Peter Buxtun and others.

1969 – CDC reaffirms need for study and gains local medical societies’ support (AMA and NMA chapters officially support continuation of study).

1972- First news articles condemn studies.

Study ends.

1973 – Congress holds hearings and a class-action lawsuit is filed on behalf of the study participants.

1974 – A $10 million out-of-court settlement is reached.

The U.S. government also promised to give lifetime medical benefits and burial services to all living participants; the Tuskegee Health Benefit Program (THBP) was established to provide these services.

1975 – Wives, widows and offspring were added to the program.

1995 – The program was expanded to include health as well as medical benefits.

1997 – On May 16th President Clinton apologizes on behalf of the United States.

1999 – Tuskegee University National Center for Bioethics in Research and Health Care hosts 1st Annual Commemoration of the Presidential Apology.

2001 – President’s Council on Bioethicsexternal icon was established.

2004 – CDC funds 10 million dollar cooperative agreement to continue work at Tuskegee University National Center for Bioethics in Research and Health Care.

2004 – The last U.S. Public Health Service Syphilis Study at Tuskegee participant dies on January 16.

2006 – Tuskegee University holds formal opening of Bioethics Center.

2007 – CDC hosts Commemorating and Transforming the Legacy of the United States Public Health Service (USPHS) Syphilis Study at Tuskegee.

2009 – The last widow receiving THBP benefits dies on January 27.

The content here can be syndicated (added to your web site).

Watch this interview with the reporter, Jean Heller, who served as a whistleblower alerting the public about what was going on:

The United States’ Experiments in Guatemala

Beginning in 1946, the National Institutes of Health, which is part of the United States government, funded research in Guatemala in which “5128 vulnerable people, including children, orphans, child and adult prostitutes, Guatemalan Indians, leprosy patients, mental patients, prisoners, and soldiers” were used for inhumane medical experimentation without their informed consent (Rodriguez & García, 2013, p. 2122). By 1948, over 1300 individuals were purposefully infected with syphilis, gonorrhea, and chancroid while others were subjected to diagnostic tests on their blood serum (Rodriguez & García, 2013). Additionally, the experiments conducted were not done in sterile environments causing additional infections, individuals were injected and re-injected with multiple types of STIs, and were withheld treatment (Rodriguez & García, 2013). John C. Cutler, the main researcher, and his colleagues purposefully withheld information from the public and did not publish anything about the experiments they were conducting because they knew many would find it unethical (Spector-Bagdady & Lombard, 2019). Cutler donated his records to the University of Pittsburgh School of Public Health, and it wasn’t until 2003 that the historian, Susan Reverby, discovered the documents (Spector-Bagdady & Lombard, 2019). After 7 years of trying to uncover the truth of what happened, Reverby presented her findings and alerted the CDC, and President Obama instructed the U.S. Presidential Commission for the Study of Bioethical Issues (PCSBI) to conduct a thorough review of what had occurred (Spector-Bagdady & Lombard, 2019). “As of February 2019—despite repeated calls for compensation—no governmental, organizational, or institutional responses have focused on identifying or making reparations to still‐living subjects of the Guatemala experiments or their relatives. The only direct advocacy on behalf of the subjects came from the private lawsuits that, nine years after public revelation and sixty years after the studies occurred, have yet to provide a remedy to the subjects or their families” (Spector-Bagdady & Lombard, 2019, p. 33).

Disclaimer: This video is not required to view due to the upsetting nature of the content.

Research and Community Outreach Moving Forward

Instead of ignoring the painful history of STI research, healing is not possible without first addressing the harms done by researchers. Fear and distrust remain among communities that have been abused and disenfranchised, and the United States government holds the blame in many cases along with individuals who knowingly supported these inhumane projects. At the same time, allyship and advocacy have also been documented as Jean Heller, the researcher breaking the news to the public about what was happening in Tuskegee, and Susan Reverby, the historian who uncovered the truth about the experiments being conducted in Guatemala, worked to bring the truth to the public’s attention.

In moving forward, how can we make sure that communities who are most vulnerable are represented and supported by treatment and educational outreach programs? What are the specific needs and concerns for those who are BIPOC, LGBTQIA+, neuroatypical, differently-abled/disabled, adolescents, young adults, and older? How can we make sure people with these various intersecting identities can receive the best preventative education, care, and treatment possible?

Licenses & Attributions

Centers for Disease Control and Prevention Creative Commons Attribution 3.0 License.

Journeyman Pictures (2011, July 11). The Frightening Legacy of US Syphilis Experiments in Guatemala [Video]. https://www.youtube.com/watch?v=nha9MsSSKvE. License: All Rights Reserved. License Terms: Standard YouTube license.

Newsy (2016, August 25). The unknowns about the Tuskegee syphilis study [Video]. https://www.youtube.com/watch?v=J3tQ93fQf8U. License: All Rights Reserved. License Terms: Standard YouTube license.

Planned Parenthood (2017, April 3). How to Talk About Having Safer Sex [Video]. https://www.youtube.com/watch?v=GTFixZ2Ic9Q. License: All Rights Reserved. License Terms: Standard YouTube license.

Planned Parenthood (2017, April 3). How to Talk About STDs and Screening [Video]. https://www.youtube.com/watch?v=tkVcpxOYhd8&t=4s. License: All Rights Reserved. License Terms: Standard YouTube license.

Planned Parenthood (2017, April 3). How to Tell Someone You Have an STD [Video]. https://www.youtube.com/watch?v=xxV7CiE2Bwc&t=3s. License: All Rights Reserved. License Terms: Standard YouTube license.

References

American Sexual Health Association (ASHA). (2021). MGen: The STI you’ve (probably) never heard of.

American Sexual Health Association (ASHA). (2020). STDs/STIs: Statistics.

Britannica, T. Editors of Encyclopaedia (2020, February 20). Sexually transmitted disease. Encyclopedia Britannica.

Centers for Disease Control and Prevention (CDC). (2016a). CDC fact sheets. Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

Centers for Disease Control and Prevention (2016b). How to use condoms and other barriers. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

Centers for Disease Control and Prevention (2020). How you can prevent sexually transmitted diseases. Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

Centers for Disease Control and Prevention (2014). Which STD tests should I get? Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

Lehmiller J. J. (2015). A comparison of sexual health history and practices among monogamous and consensually nonmonogamous sexual partners. The Journal of Sexual Medicine, 12(10), 2022–2028. https://doi.org/10.1111/jsm.12987

National Institutes of Health (NIH). (2017a). Treatments for specific types of sexually transmitted diseases and sexually transmitted infections (STDs/STIs).

National Institutes of Health (NIH). (2017b). What are the symptoms of sexually transmitted diseases (STDs) or sexually transmitted infections (STIs)?

North, A. L., & Niccolai, L. M. (2016). Human papillomavirus vaccination requirements in US schools: Recommendations for moving forward. American Journal of Public Health, 106(10), 1765–1770. https://doi.org/10.2105/AJPH.2016.303286

Planned Parenthood. (2021a). How do I buy internal condoms?

Planned Parenthood. (2021b). Sex toys.

Rodriguez, M. A., & García, R. (2013). First, do no harm: the US sexually transmitted disease experiments in Guatemala. American Journal of Public Health, 103(12), 2122–2126. https://doi.org/10.2105/AJPH.2013.301520

Spector-Bagdady, K., & Lombard, P. (2019). U.S. Public Health Service STD experiments in Guatemala (1946–1948) and their aftermath. Ethics & Human Research, 41(2), 29-34. https://doi.org/10.1002/eahr.500010